The bitter sweet – the ‘free sugars’ debate

There is no doubt that obesity has become one of the biggest health concerns for the developed world in the 21st century and, while the UK comes out better than the US in comparisons of obesity rates, it does not compare well with other European countries. This is one reason the 'Carbohydrates and Health' report published earlier this year by the Scientific Advisory Committee on Nutrition (SACN) has garnered a lot of attention.

Statistics from the Health and Social Care Information Centre show high rates of obesity in the UK, with a rise in prevalence among men in England from 13.2% in 1993 to 24.4% in 2012, while the rate among women rose from 16.4 to 25.1%. A ranking of 188 countries with the highest percentage of population classified as overweight or obese compiled by Ramon Martinez, a technical specialist in health metrics at the World Health Organization (WHO), put the US in 27th place and the UK 35th. A separate study of European nations found only Hungary has more overweight adults than the UK.

It is no surprise, therefore, that tackling obesity remains a policy priority for the UK Government. In May, Jeremy Hunt used his first speech as secretary of state for health to highlight the "great scandal that one in five children leave primary school clinically obese" and to promise action on public health.

Guidelines for a healthy carbohydrate intake vary in different countries and have changed over time (see table, above right), but one thing has remained constant in recent years: sugar is seen by some as one of the main culprits in causing obesity, type 2 diabetes, cardiovascular disease and other major health problems.

Food health campaigner and renowned chef Jamie Oliver has taken up the cause, and recently praised Brighton and Hove City Council for considering a voluntary tax on sales of sugary drinks that could see participating restaurants and food outlets levy a 10p additional charge on soft drinks with added sugar. Oliver, who supports a wider sugar tax that the current government does not consider viable, praised the symbolic move and stressed that sugary drinks are "a treat and not hydration".

One of the key recommendations of the SACN report, which did not just look at sugar but also at the wider role of carbohydrates in a healthy diet, was a reduction in intakes of free sugars from 10% to no more than 5%, based on sugar's contribution to increasing energy intakes (how many calories we eat)

Beyond the guidelines

The last major study of UK food policy on carbohydrates was performed by the Committee on the Medical Aspects of Food Policy (COMA) in the 1980s and 1990s; SACN believes that, since then, much more evidence has emerged on the role of carbohydrates in cardiometabolic, colorectal and oral health. Its seven-year investigation of the link between dietary carbohydrates and health has taken in evidence from prospective cohort studies and randomised controlled trials, and this has led it to conclude that total carbohydrate intake appears to be neither detrimental nor beneficial to those health risks, and that diets higher in total carbohydrate do not necessarily cause weight gain.

The SACN report does, however, highlight specific components or sources of carbohydrates that do have certain detrimental health effects. For instance, it cites evidence that greater consumption of sugar-sweetened beverages is associated with a higher risk of type 2 diabetes among children and adolescents and leads to greater weight gain than non-calorifically sweetened beverages.

Among its recommendations is that a new definition of dietary fibre be adopted in the UK and that a definition of 'free sugars' be used in nutrition advice in place of 'non-milk extrinsic sugars'. The only difference in the definition is that non-milk extrinsic sugars include 50% of the fruit sugars from stewed, dried or canned fruit, while free sugars include none.

Furthermore, it suggests carbohydrates should still make up approximately 50% of total intake, dietary fibre for adults should be increased to 30g a day and that population average intake of free sugars should not exceed 5% of total dietary energy.

Concerns about the recommendations surfaced quickly. Some felt that changes would only confuse the public. Other analysts were concerned about whether the burden of meeting the new guidelines would lie too heavily on food manufacturers. The Food and Drink Federation (FDF), which represents food manufacturers in the UK, believes that achieving the new goals will be a stretch.

"The first thing to highlight is that we, as a nation, consume more than the dietary recommendations even before the change, for all age groups," says Kate Halliwell, the FDF's nutrition and health manager. When it comes to sugar specifically, the report shows that consuming more calories leads to diabetes, tooth decay and obesity, but those come from overconsumption of carbohydrates in general, not just sugar."

"Changing the guidelines will not be effective on its own. Most people would not know what the guidelines were anyway, though it may help to change the focus for policymakers. It is also important to note that the UK Government's own data shows that sugar consumption is coming down.

"Defra [the Department for Environment, Food and Rural Affairs] looks at the typical shopping basket for a household, and the National Diet and Nutrition Survey tracked the food diaries of consumers, and the trend is that sugar consumption is already moving down althought it is still above recommended levels," she adds.

Furthermore, notes Halliwell, the SACN report focuses on more than just sugar. It makes recommendations, for example, about dietary fibre and highlights that diets rich in fibre are associated with lower incidence of cardiovascular disease, type 2 diabetes and colorectal cancers. "The SACN report looks at fibre, for which consumption is too low. You should not demonise one ingredient like sugar - you need to focus on a balanced diet," she remarks.

Collaborating on carbs

Halliwell is happy to admit that food manufacturers have a role to play in helping formulate public health policy.

"We need to build on the work that we have already done. We are engaged with the government on behalf of food manufacturers, but we must not get hung up on sugar. The government is looking particularly at obesity, so the focus is on calories. We need, therefore, to think about total energy consumption and not just sugar," she explains.

"We cannot control what consumers buy and eat, but food manufacturers do have a role in offering choice. When it comes to treat foods, for example, we can look at appropriate portion sizes, or we could increase the use of healthier ingredients such as wholegrain, and fruit and vegetables in convenience foods."

The industry has made great strides in helping consumers understand what is in their food. It emphasises that there should be clear nutritional information, no hidden ingredients and, as a result, informed choice.

"Clear labelling of nutritional information ensures that customers can make informed choices. We have to present that information clearly. People shop quickly, and nutritional information must be clear, but some consumers will focus on cost and their choice of what they want to eat.

"Research shows that when people are made to look at nutritional information, they understand it, but that may not be at the front of their minds when they are making purchasing decisions," Halliwell stresses.

Something to build on

FDF acts as the voice of the UK food and drink industry, which is the country's largest manufacturing sector and comprises more than 6,000 businesses. The organisation's aim is to communicate the industry's concerns to government, regulators and consumers. In providing a forum for discussion it has been party to the industry's efforts to address public health issues through innovative means such as investigating alternatives to reformulation.

For example, it is hard to change the formulation of chocolate, so it may be helpful to look at portion sizes instead. Halliwell notes that many of the UK's leading confectioners have already agreed a cap on the size of a single portion.

"The important thing is to have dialogue. With any change in product formulation, you must take your consumers with you or they won't buy your food. Look at the change in salt formulation; with that, a slow and steady approach was taken," says Halliwell. "We have had long-standing discussions with the government and, now, there is more of a focus on sugar - whereas, with the previous government, the focus was on energy alone, of which sugar is only one part," she says.

"There has already been a lot of change. Over the past few years, there has been an 8% decrease in the calories in soft drinks, of which 7% comes from reducing sugar, and there has been a big move towards diet or zero-calorie drinks.

"We must work with the government more to build on this and to support the continuation of voluntary programmes that allow food companies to be flexible in their response. They know their products and they know their consumers. We have seen manufacturers remove trans fats from foods and there has been a fall in the level of salt content, so the industry has shown itself to be a reliable partner," says Halliwell.

FDF has welcomed the SACN report but wants to ensure that policy does not take a narrow focus on sugar. It hopes the report will be a platform on which to build a sensible, collaborative approach towards informing consumers' decisions.

"It comes down to behaviour - the choices people make about the range of foods in their diet and the amount of physical activity in their lives. Most people know what they should be doing. Everyone needs to play a part - regulators, food manufacturers, consumers and many more, including the out-of-home sector. There is no single big change that will solve this problem," says Halliwell.

"Education is part of the solution, and nutrition is on the school curriculum now as part of the government's long-term strategy. It is great to have the SACN report because it looks at evidence only, not policy.

"We have seen with salt and, in some cases, portion sizes that the voluntary approach works. One-size-fits-all regulation does not work. Science is useful because it informs policy, but the formulation of policy to meet all dietary needs ultimately needs to involve all parties."